INSTRUCTIONS:
Please TYPE or PRINT all
information.
The University of Akron
Graduate School
Application for NE Ohio ACHIEVE
First Application to Graduate School
Re-Application to Graduate School
PERSONAL DATA
E-Mail Address
University of Akron Student ID number (if applicable)
Last Name
Other Names Used
First Name
Last
Middle
First
Name as Reflected on Passport (International Students Only) Last Name
Permanent Address Street
First Name
Middle
City
Province (non U.S.)
State
Country (non U.S.)
Zip/Postal Code
Ohio County
City, State, Country of Birth
Mailing Address
Street
City
State
Zip/Postal Code
If same as permanent
address check here
Phone No. (including area code)-U.S only
Date of Birth MO
DAY
YEAR
Gender
M
Name of person to contact in case of emergency (Last Name, First Name)
Address of Emergency Contact Street
Relation (check one)
Parents
Father
City
Mother
State
Guardian
Zipcode
Spouse
Phone No. (U.S. only)
Other
Check One (optional)
Native American
African American
U.S Citizen
Yes
Asian American
Chicano/Latino
Country of Citizenship (non U.S.)
Caucasian/White
Native Language
No
If you are not a U.S. citizen, indicate your current status:
Non-Immigrant. If you hold a visa, indicate visa type (e.g.F-1, J-1, etc.)
U.S. Permanent Resident, Immigrant, Refugee, or Asylee
Alien Registration Number
Date Received MONTH DAY
Permanent residence location
Ohio
State other than Ohio
Date Ohio Residency Established
YEAR
U.S. Citizen living abroad
MONTH
Have you ever been convicted of a criminal offense?
Yes
No
DAY
Non U.S
YEAR
F
PROGRAM DATA
Intended Program of Study
NE Ohio ACHIEVE
Select appropriate program classification
Full
Streamlined
Master’s Program
Non-Degree Status
Doctoral Program
Certificate Program
Program Code:
Non-degree
Term for which application is sought:
Fall Semester 20
Spring Semester 20
Summer Semester 2016
I am applying for a Graduate Assistantship:
Yes
No
EDUCATION (including The University of Akron or institution currently attending, if any)
Complete the following section for all universities, colleges, schools of nursing, technical schools, or other postsecondary educational institutions you
have attended or are now attending. Request from each institution, except The University of Akron, that an official copy of your transcript be sent
directly to Diane Hergenrather, Dept of Curricular & Instructional Studies, The University of Akron, Akron, OH 44325-4205.
College/University/School
Major
Location
From:
Degree/Certificate Completed or Anticipated
Major
Location
From:
MO
Major
Location
From:
MO
Date Completed or Anticipated
MONTH
YEAR
To:
MO
YR
Name of Degree Awarded, if any:
YR
Date Completed or Anticipated
MONTH
YEAR
College/University/School
Degree/Certificate Completed or Anticipated
YR
Date Completed or Anticipated
MONTH
YEAR
College/University/School
Degree/Certificate Completed or Anticipated
MO
To:
MO
YR
Name of Degree Awarded, if any:
YR
To:
MO
YR
Name of Degree Awarded, if any:
Are you currently under suspension or dismissal for disciplinary reasons from any college, university or other formal education program:
Yes
No
(If yes, please attach a statement of explanation)
Date last attended The University of Akron (if applicable)
Month
Degree/Certificate Completed or Anticipated
Year
CERTIFICATE OF TRUTH STATEMENT (Please read the following and sign below)
I affirm that the information I have provided on this application form and all other admission application materials is complete, accurate, and true
to the best of my knowledge. I authorize each college or school I have attended to release academic and personal information as related to this
admission application upon request. I agree to submit other materials which are required for this admission application. I agree that, as a student, I
will be subjected to the rules and policies set forth in the Graduate and Undergraduate Bulletins by The University of Akron. I understand that
furnishing false or incomplete information on any part of this admission application may result in cancellation of admission or registration or both.
X
Date:
(Write, Do Not print your legal signature)